Breastfeeding and Maternal Nutrition
Frequently Asked Questions (FAQ)

FAQ Sheetis a series of publications of Frequently Asked Questions on topics addressed by the
LINKAGES Project. This issue focuses on the impact of maternal nutrition on breastmilk quantity and
quality, the nutritional requirements of lactating women, the impact of breastfeeding on maternal health, and implications of this information for programs.Download pdfEnglish,
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FAQ SHEET 4 Updated July 2004

Effect of Breastfeeding on Maternal Nutrition

Does breastfeeding affect the mother's nutritional status?It can, depending on the mother's diet. The energy, protein, and other nutrients in breastmilk come from the mother's diet or from her own body
stores. When women do not get enough energy and nutrients in their diets, repeated, closely spaced cycles of pregnancy and lactation can reduce
their energy and nutrient reserves, a process known as maternal depletion. However, there are also adaptations that help protect
the mother from these effects. The most important is appetite. During pregnancy and particularly during lactation, a woman's appetite generally increases. The resulting increase
in food intake helps meet the additional demands of pregnancy and lactation. Extra food, therefore, must be made available to the mother.

Community and household members should be informed of the importance of making additional food available to women before
they become pregnant, during pregnancy and lactation, and during the recuperative interval when the mother is neither pregnant
nor lactating. Making more food available to mothers is even more important in societies with cultural restrictions on women's diets.
Efforts to increase the amount of food available to adolescent, pregnant, and lactating women can be the most effective way of
improving their health and that of their infants.

Summary of Main Points

Unless extremely malnourished, virtually all mothers can produce adequate amounts of breastmilk. When the breastfeeding mother
is undernourished, it is safer, easier, and less expensive to give her more food than to expose the infant to the risks associated
with breastmilk substitutes.

Maternal deficiencies of some micronutrients can affect the quality of breastmilk. These deficiencies
should be avoided by improving the diet or providing supplements to the mother.

Lactation places high demands on maternal stores of energy and protein. These stores need to be established, conserved, and replenished.

Delay of the first birth and adequate birth spacing help ensure that maternal stores are sufficient for healthy pregnancy and lactation.

Breastfeeding provides health benefits to the mother as well as to the infant.

How much
extra food does a breastfeeding mother need?

To support lactation and maintain maternal reserves, most mothers in developing
countries will need to eat about 500 additional kilocalories every day (an
increase of 20 percent to 25 percent over the usual intake before pregnancy).
Well-nourished mothers who gain enough weight during pregnancy need less because
they can use body fat and other stores accumulated during pregnancy. Lactation
also increases the mother’s need for water, so it is important that she drink
enough to satisfy her thirst.

Should
certain foods be eaten or avoided by breastfeeding mothers?

No. There are no specific foods that must be eaten or avoided by the
breastfeeding mother, despite what many people think. Food rules (eat this,
avoid that) can cause harm by reducing the mother’s ability to choose a balanced
diet or by discouraging her from breastfeeding. Consumption of a variety of
foods is the best dietary advice.

Effect of Maternal Nutrition on Breastfeeding

Yes. In all but the most extreme cases, malnourished mothers can follow the same
recommendations for breastfeeding as mothers who are not malnourished. These
recommendations include exclusive breastfeeding1 for six months followed by
on-demand breastfeeding and the introduction of complementary foods.

There is a common misconception that malnutrition greatly reduces the amount of
milk a mother produces. Although malnutrition may affect the quality of milk,
studies show that the amount of breastmilk produced depends mainly on how often
and how effectively the baby sucks on the breast. If a mother temporarily
produces less milk than the infant needs, the infant responds by suckling more
vigorously, more frequently, or longer at each feeding. This stimulates greater
milk production. When the breastfeeding mother is under-nourished, it is safer,
easier, and less expensive to give her more food than to expose an infant under
six months of age to the risks associated with feeding breastmilk substitutes or
other foods.2

Can
breastmilk production be increased by giving the mother additional food?

Some evidence suggests it can. Two randomized intervention trials, in Burma and
Guatemala, have so far been conducted to answer this question. In both studies,
food supplementation of malnourished lactating mothers resulted in a small
increase in infant milk intake. In another study in Indonesia, maternal
supplementation during pregnancy improved infant growth rates, possibly by
increasing breastmilk production. Therefore, although maternal malnutrition is
not considered an important constraint to breastfeeding for most mothers, giving
additional food to malnourished mothers during pregnancy and/or lactation may
help increase milk production and will certainly improve their own nutritional
status and provide additional energy to care for themselves and their families.

1 Exclusive breastfeeding means giving no other foods or liquids, not even
water.2 These substitutes are less nutritious than breastmilk, lack antibodies to
fight infections, and often carry germs and other contaminants.

Should
breastfeeding mothers take extra vitamins and minerals?

It depends on the mother’s diet. Breastmilk is rich in the vitamins and minerals
needed to protect an infant’s health and promote growth and development. If the
mother’s diet is poor, the levels of micronutrients in breastmilk may be reduced
or the mother’s own health may be affected. It is therefore important that the
mother’s micronutrient intake is adequate. A diverse diet containing animal
products and fortified foods will help ensure that the mother consumes enough
micronutrients for both herself and her breastfeeding infant. If a diverse diet
is not available, a micronutrient supplement may help.

For example, in areas where vitamin A deficiency is common, it is currently
recommended that all mothers take a single high-dose supplement of 200,000
international units3 (IU) of vitamin A as soon as possible after delivery.
Studies have shown that such a supplement improves the vitamin A levels in the
mother, in breastmilk, and in the infant. High doses of vitamin A are not
recommended for women during pregnancy or later than eight weeks after delivery
(or later than six weeks if the mother is not breastfeeding) because too much
vitamin A may cause damage to the developing fetus. Although high doses during
pregnancy can be dangerous, daily (<8,000 IU) or weekly (<25,000 IU) low-dose
vitamin A supplements during pregnancy can reduce maternal night blindness and
death.

The levels of thiamin, riboflavin, vitamin B-6, vitamin B-12, iodine, and
selenium in breastmilk are also affected by how much is in the food the mother
eats. In areas where deficiencies of these micronutrients are common, increasing
the mother’s intakes through improved diets or supplements will primarily
improve breastmilk quality and infant nutrition.

Other micronutrients (such as folate, calcium, iron, copper, and zinc) remain at
relatively high levels in breastmilk even when the mother’s reserves are low.
This means that the breastfeeding mother’s own reserves can be used up and that
it is primarily the mother herself who will benefit if she eats more food high
in these micronutrients. Additional calcium and iron, in particular, are often
needed to protect maternal reserves.

Effect of Breastfeeding on Maternal Health

Does
breastfeeding benefit the mother’s health?

Yes. Breastfeeding has many positive effects on the mother’s health. One of the
most important is lactational infertility. This is the period of time after
giving birth that the mother does not become pregnant due to the hormonal
effects of breastfeeding. Studies show that this effect is greater when the
infant suckles more frequently and is exclusively breastfed. Increasing the
interval between births has benefits for the mother and her children.

Fewer pregnancies reduce the mother’s risk of maternal depletion and maternal
death. A related effect is lactational amenorrhea, the period of time after
giving birth that the mother does not menstruate due to the same hormonal
effects of breastfeeding. This is the basis for the lactational amenorrhea
method (LAM)4 of contraception. Lactational amenorrhea also reduces the amount
of menstrual blood loss, which helps to prevent anemia by conserving the
mother’s iron stores.

There are many other benefits of breastfeeding for the mother. Breastfeeding
immediately after delivery stimulates contraction of the uterus. This may help
reduce loss of blood and risk of hemorrhage, a major cause of maternal
mortality. There is good evidence that breastfeeding reduces the risk of ovarian
and breast cancer and helps prevent osteoporosis.

3 This recommendation is currently under
review and may be increased, pending the results of on-going research.

4 LAM is defined by three criteria: 1)
the woman’s menstrual periods have not resumed, AND 2) the baby is fully or
nearly fully breastfed, AND 3) the baby is less than six months old. If all
three criteria are met, the risk of pregnancy is less than 2 percent.

Does
breastfeeding affect the health of mothers with HIV?

Although one study suggested that lactation accelerated progression to AIDS,
later studies did not support this finding. A 2001 study in Kenya comparing
breastfeeding with artifical feeding reported that HIV-positive mothers who
breastfed were at greater risk of death than those who used infant formula. This
study has been criticized for various flaws in its methods and interpretation.
Three subsequent attempts to verify the findings—in Tanzania, in South Africa,
and in a pooled analysis of nine clinical trials—found no relationship between
infant feeding pattern and the health of HIVpositive mothers.

Both HIV infection and lactation increase nutritional requirements. HIV-positive
mothers who breastfeed need access to sufficient food of adequate quality to
meet these increased nutritional needs and to protect their stores. They should
be counseled about the health and nutritional effects of breastfeeding for
themselves and their children. Existing evidence does not suggest that concerns
about the impact of breastfeeding on an HIV-positive mother’s health should be
the basis for the infant feeding decision. The main concern is the balance of
risks and benefits of breastfeeding for the infant.

Program Implications and Guidelines

What can
programs do to support breastfeeding and maternal nutrition?

Information presented in this FAQ has implications for the distribution of food
in the household, the division of labor, and the delivery of services to women.
Women’s nutritional status is threatened by repeated, closely spaced
pregnancies, inadequate energy intake, micronutrient deficiencies, infections,
parasites, and heavy physical labor. Health services and agricultural extension
services, secondary schools, women’s groups, and other outreach networks provide
opportunities to promote better infant feeding and maternal dietary practices
and to offer preventive care and counseling. Health care providers can help
improve maternal nutrition by counseling women about breastfeeding, increased
food intake, dietary diversification, work-load reduction, and family planning
(including delaying the first birth, birth spacing, and options for limiting
family size). They can also assess a woman’s need for antimalarials, hookworm
medication, and micronutrient supplementation and provide appropriate treatment.

For undernourished populations and populations displaced by war and natural
disasters, the use of breastmilk substitutes can be particularly dangerous. The
best solution is to feed the mother, not the infant, and to give her whatever
support she needs for breastfeeding. Providing additional foods and fluids to
the mother helps both mother and child.

The time for intervention should not be limited to periods of pregnancy and
lactation. Adequate nutrition is a cumulative process. In fact, birth outcome is
strongly influenced by the mother’s nutritional status even before she becomes
pregnant. The recuperative interval between lactation and the next pregnancy
also offers an opportunity to replenish the mother’s energy and micronutrient
reserves.

The recommendations in the box on page 5 are suggested to improve the nutrition
of adolescent girls and women of reproductive age. These recommendations,
coupled with optimal breastfeeding and complementary feeding practices, will
contribute to good health and nutrition throughout the life cycle.

Recommended Practices to Improve
the Nutrition of
Adolescent Girls (10-19 Years) and Women of Reproductive Age Recommended at all times

Increase food intake, if underweight, to protect adolescent girls’ and
women’s health and establish reserves for pregnancy and lactation.

Diversify the diet to improve the quality and micronutrient intake.

Increase daily consumption of fruits and vegetables.

Consume animal products, if feasible.

Use fortified foods, such as vitamin A-enriched sugar and other
products and iron-enriched and vitamin-enriched flour or other staples,
when available.

Use iodized salt.

If micronutrient requirements cannot be met through available food
sources, supplements containing folic acid, iron, vitamin A, zinc,
calcium, and other nutrients may be needed to build stores and improve
women’s nutritional status.

Recommended during periods of
special needs

At certain times, girls and women have heightened nutritional
requirements. During these times, they should follow the above
recommendations plus those listed below. During adolescence and before pregnancy

Increase food intake to accommodate the adolescent “growth spurt” and
to establish energy reserves for pregnancy and lactation.

Delay the first pregnancy to help ensure full growth and nutrient
stores.

Eat the equivalent of an additional, nutritionally balanced meal per
day.

In areas where vitamin A deficiency is common, take a high-dose
vitamin A capsule (200,000 IU) as soon after delivery as possible, but no
later than 8 weeks postpartum to build stores, improve the vitamin A
content of breastmilk, and reduce infant and maternal morbidity.

Use the lactational amenorrhea method (LAM) and other appropriate
family planning methods to protect lactation, space births, and extend the
recuperative period.

During the interval between stopping lactation
and the next pregnancy Plan and ensure an adequate period (at least six months) between stopping
lactation and the next pregnancy to allow for the necessary build-up of
energy and micronutrient reserves.

Merchant K, Martorell R, Haas J. Maternal and fetal responses to the stresses of
lactation concurrent with pregnancy and of short recuperative intervals.
American Journal of Clinical Nutrition 52:280-288, 1990.

Breastfeeding and Maternal Nutrition Frequently Asked Questions (FAQ) is
a publication by LINKAGES: Breastfeeding, LAM, Related Complementary Feeding,
and Maternal Nutrition Program, and was made possible through support provided
to the Academy for Educational Development (AED) by the Bureau for Global Health
of the United States Agency for International Development (USAID), under the
terms of Cooperative Agreement No. HRN-A-00-97-00007-00. The opinions expressed
herein are those of the author(s) and do not necessarily reflect the views of
USAID or AED.